Pt assessment Flashcards
1
Q
What to include in a referral?
A
- Pt demographics - name, DOB, tel num, address, NHS num
- Name and address of GMP
- Translation needs
- Summary of clinical problem
- Relevant MH and SH
- Provisional diagnosis
- What you would like specialist to do
- Statement of urgency of referral
- Relevant radiographs and photographs
2
Q
What to ask in history taking?
A
- How can I help?
- HPC - use SOCRATES
- MH
- Review of systems - any undiagnosed health problems
- Medx history
- Allergies and ADRs
- SH
- FH
- DH
- Summarise all findings back to pt
3
Q
Review of systems
- What to ask about cardiovascular?
A
- Chest pain?
- Shortness of breath?
- Palpitations?
4
Q
Review of systems
- What to ask about respiratory?
A
- Wheezing?
- Persistent cough?
- Phlegm / sputum cough?
5
Q
Review of systems
- What to ask about GI?
A
- Vomitting / diarrhoea / constipation?
- Choke on liquid / solid food?
- Unexplained weight loss?
- Abdominal pain?
- Blood / mucus in stool?
6
Q
Review of systems
- What to ask about musculoskeletal?
A
- Joints swell / hot?
- Joint stiffness / locking?
- Effects of movement?
7
Q
Review of systems
- What to ask about neurological?
A
- Fits / faints?
- Headaches?
- Visual disturbances?
- Weakness / odd sensation?
8
Q
Review of systems
- Which other general bodily systems ask about?
A
- Skin
- Genitourinary
- Endocrine
9
Q
How to take medx history?
A
- Prescription / OTC?
- Recreational?
- What is it prescribed for?
- Recently stopped drugs? - ADRs?
- Name of drug, dosage, frequency, route of admin, period taken for
10
Q
Asking about allergies and ADRs?
A
- What happened?
- When?
- What rxn?
- Action taken?
11
Q
What should you do in pt exam?
A
- General observations - mobility, hygiene, tremor
- Mental state - anxious, low mood, agitated
- Exposed skin - flush, rashes, scars, bruises, lesions, nails, joint swellings
- TMJ
- Mouth opening
- Salivary glands
- Lymph nodes
- CNs
- MoM
12
Q
Which lymph nodes examine?
A
- Occipital
- Posterior auricular
- Preauricular
- Submandibular
- Submental
- Supraclavicular
13
Q
What is lymphadenopathy and how can it present?
A
- Disease of lymph nodes
- Enlarged
- Solitary or multiple nodes
- Painless or tender
- Smooth or irregular
- Mobile or fixed to superficial / deep tissue
14
Q
What is lymphadenitis and how does it present?
A
- Inflamed LNs
- Red, painful, tender, enlarged
15
Q
Functions of LNs?
A
- Filter lymph - protect body from infection
- Produce and mature lymphocytes
- Staging post for cells of immune system
